[Ultrasound visualization of the guidewire and positioning of the central venous catheter : A prospective observational study]. / Sonographische Visualisierung des Führungsdrahtes und Positionierung des zentralen Venenkatheters : Eine prospektive Beobachtungsstudie.

BACKGROUND: After insertion of a central venous catheter (CVC) the catheter position must be controlled and a pneumothorax ruled out. OBJECTIVE: The aim was to examine whether the use of two standard acoustic windows known from emergency sonography examination techniques is feasible to 1) verify the correct intravenous localization and direction of the guidewire before final CVC insertion and 2) correctly predict the required CVC length for positioning of the catheter tip in the lower third of the superior vena cava. MATERIAL AND METHODS: This single center prospective observational study included adult patients (age ≥18 years) with an indication for CVC insertion after institutional ethics approval was obtained. Puncture sites were restricted to bilateral internal jugular and subclavian veins and except for duplicate examinations no further exclusion criteria were defined. After vessel puncture and insertion of the guidewire, the vena cava was displayed by an additional ultrasound examiner (sector scanner 1.5-3.6 MHz) using the transhepatic or subcostal acoustic window to localize the guidewire. For positioning of the CVC tip, the required catheter length in relation to the cavoatrial junction was measured using the guidewire marks during slow retraction and consecutive disappearance of the J­shaped guidewire tip from each acoustic window. From the resulting insertion length of the guidewire 4 cm was subtracted for the transhepatic and 2 cm for the subcostal window under the assumption that this length correlates to the distance from the cavoatrial junction. The CVC was finally inserted and a chest radiograph was performed for radiological verification of the CVC position. RESULTS: Of 100 included patients, 94 could finally be analyzed. The guidewire could be identified in the vena cava in 91 patients (97%) within a time period of 2.2 ± 1.9 min. In three patients, the wire could not be visualized, although two catheters had the correct position, while one catheter was incorrectly positioned in the opposite axillary vein. In the second study part, positioning of the CVC was evaluated in 44 of the 94 patients. In 5 of these 44 patients, the correct direction and disappearance of the guidewire from the acoustic window could also be reliably visualized; however, with the left subclavian vein as the puncture site, the respective catheters were up to 6 cm too short for correct positioning. Thus, these 5 patients were excluded from this analysis. In the remaining 39 patients, the position of the CVC tip was optimally located in the lower third of the superior vena cava according to the chest radiograph in 20 patients (51%), while it was relatively too high in 5 patients (13%) and too low (entrance of the right atrium) in 9 patients. In the other 5 patients, disappearance of the guidewire from the acoustic window was not definitely detectable. CONCLUSION: The presented intraprocedural ultrasound-based method using two standard acoustic windows is reliable for verification of the correct intravenous location and direction of the guidewire even before dilatation of the vessel puncture site for insertion of the catheter. Furthermore, the method allows the clinically acceptable measurement of the required length for catheter positioning. A chest radiograph can be waived provided the ultrasound examination (identification of the guidewire and exclusion of puncture-related complications such as pneumothorax) is unambiguous.

[Study protocol to improve the quality of delirium management in intensive care]. / Protokoll einer Studie zur Qualitätsverbesserung des Delirmanagements auf der Intensivstation.

BACKGROUND: Delirium in cardiac surgery patients is common and is associated with prolonged mechanical ventilation and hospital stay as well as higher mortality. Protocols may improve outcome. In our cardiac surgery intensive care unit (ICU), patients with delirium have not received standardized treatment so far. HYPOTHESIS: In cardiac surgery ICU patients, standardized delirium management will lead after a 4­week introduction, compared to nonstandardized treatment, to a reduction of delirium duration. METHODS: Prospective before/after study to evaluate a quality improvement project for delirium management over 12 weeks including 140 patients. INCLUSION CRITERIA: (a) ≥18 years, (b) consent for research with their data. EXCLUSION CRITERIA: (a) palliative status, (b) present during both the before/after phase, (c) pregnancy, (d) included in a competitive study, or (e) delirium not assessable. The implementation includes the introduction of a protocol with interprofessional training, bedside-teaching, pocket cards, posters, and reminders. The primary outcome is the duration of delirium, assessed four times a day with validated instruments. Secondary outcome measures include delirium incidence, duration of mechanical ventilation, length of stay in ICU and hospital, mortality, nursing/therapeutic interventions, cumulative doses of delirium-related drugs, and complications of delirium for a follow-up of 28 days. Empirical data will be analyzed with descriptive and inferential statistics. OBJECTIVES: The purpose of the study is a reduction of the duration and frequency of delirium in cardiac ICU patients and will provide evidence of the effect size of the introduction of a delirium management.

Global and regional assessment of sustained inflation pressure-volume curves in patients with acute respiratory distress syndrome.

OBJECTIVE: Static or quasi-static pressure-volume (P-V ) curves can be used to determine the lung mechanical properties of patients suffering from acute respiratory distress syndrome (ARDS). According to the traditional interpretation, lung recruitment occurs mainly below the lower point of maximum curvature (LPMC) of the inflation P-V curve. Although some studies have questioned this assumption, setting of positive end-expiratory pressure 2 cmH2O above the LPMC was part of a 'lung-protective' ventilation strategy successfully applied in several clinical trials. The aim of our study was to quantify the amount of unrecruited lung at different clinically relevant points of the P-V curve. APPROACH: P-V curves and electrical impedance tomography (EIT) data from 30 ARDS patients were analysed. We determined the regional opening pressures for every EIT image pixel and fitted the global P-V curves to five sigmoid model equations to determine the LPMC, inflection point (IP) and upper point of maximal curvature (UPMC). Points of maximal curvature and IP were compared between the models by one-way analysis of variance (ANOVA). The percentages of lung pixels remaining closed ('unrecruited lung') at LPMC, IP and UPMC were calculated from the number of lung pixels exhibiting regional opening pressures higher than LPMC, IP and UPMC and were also compared by one-way ANOVA. MAIN RESULTS: As results, we found a high variability of LPMC values among the models, a smaller variability of IP and UPMC values. We found a high percentage of unrecruited lung at LPMC, a small percentage of unrecruited lung at IP and no unrecruited lung at UPMC. SIGNIFICANCE: Our results confirm the notion of ongoing lung recruitment at pressure levels above LPMC for all investigated model equations and highlight the importance of a regional assessment of lung recruitment in patients with ARDS.

Influence of tidal volume on ventilation inhomogeneity assessed by electrical impedance tomography during controlled mechanical ventilation.

The global inhomogeneity (GI) index is a parameter of ventilation inhomogeneity that can be calculated from images of tidal ventilation distribution obtained by electrical impedance tomography (EIT). It has been suggested that the GI index may be useful for individual adjustment of positive end-expiratory pressure (PEEP) and for guidance of ventilator therapy. The aim of the present work was to assess the influence of tidal volume (VT) on the GI index values. EIT data from 9 patients with acute respiratory distress syndrome ventilated with a low and a high VT of 5 ± 1 (mean ± SD) and 9 ± 1 ml kg(-1) predicted body weight at a high and a low level of PEEP (PEEPhigh, PEEPlow) were analyzed. PEEPhigh and PEEPlow were set 2 cmH2O above and 5 cmH2O below the lower inflection point of a quasi-static pressure volume loop, respectively. The lower inflection point was identified at 8.1 ± 1.4 (mean ± SD) cmH2O, resulting in a PEEPhigh of 10.1 ± 1.4 and a PEEPlow of 3.1 ± 1.4 cmH2O. At PEEPhigh, we found no significant trend in GI index with low VT when compared to high VT (0.49 ± 0.15 versus 0.44 ± 0.09, p = 0.13). At PEEPlow, we found a significantly higher GI index with low VT compared to high VT (0.66 ± 0.19 versus 0.59 ± 0.17, p = 0.01). When comparing the PEEP levels, we found a significantly lower GI index at PEEPhigh both for high and low VT. We conclude that high VT may lead to a lower GI index, especially at low PEEP settings. This should be taken into account when using the GI index for individual adjustment of ventilator settings.

Sufentanil administration guided by surgical pleth index vs standard practice during sevoflurane anaesthesia: a randomized controlled pilot study.

BACKGROUND: Evaluation of analgesia and antinociception during anaesthesia is still a challenging issue and routinely based on indirect and non-specific signs such as movement, tachycardia, or lacrimation. Recently, the surgical pleth index (SPI) derived by finger plethysmography was introduced to detect nociceptive stimulation during anaesthesia. While SPI guidance reduced the number of unwanted events during total i.v. anaesthesia (TIVA), the impact of SPI during volatile-based anaesthesia with intermittent opioid administration has not yet been elucidated. METHODS: Ninety-four patients were randomized into either SPI-guided analgesia or standard practice (Control). In both groups, anaesthesia was maintained with sevoflurane to keep bispectral index values between 40 and 60. In the SPI group, patients received a sufentanil bolus (10 µg) whenever SPI value increased above 50, whereas in the control group, sufentanil was administered according to standard clinical practice. The number of unwanted somatic events, haemodynamics, sufentanil consumption, and recovery times were recorded. RESULTS: The incidence of intraoperative unwanted somatic events was comparable between the groups (P=0.89). No significant differences with respect to hypotensive or hypertensive events were found. The mean (95% confidence interval) sufentanil consumption was non-significantly (P=0.07) reduced in the SPI group, 0.64 (0.57-0.71) vs 0.78 (0.64-0.91) µg min(-1). Recovery times were comparable between the groups. CONCLUSIONS: Sufentanil administration guided by SPI during sevoflurane anaesthesia is clinically feasible. In contrast to TIVA, it did not improve anaesthesia conduct with respect to unwanted somatic events, haemodynamic stability, sufentanil consumption, emergence time, or post-anaesthesia care unit care. Therefore, we conclude that anaesthesia regimen has an impact on beneficial effects by SPI guidance. Clinical trial registration NCT01525537. (Registered at Clinicaltrials.gov.).

Smooth-muscle contraction without smooth-muscle myosin.

Here we have used gene-targeting to eliminate expression of smooth-muscle myosin heavy chain. Elimination of this gene does not affect expression of non-muscle myosin heavy chain, and knockout individuals typically survive for three days. Prolonged activation, by KCl depolarisation, of intact bladder preparations from wild-type neonatal mice produces an initial transient state (phase 1) of high force generation and maximal shortening velocity, which is followed by a sustained state (phase 2) characterized by low force generation and maximal shortening velocity. Similar preparations from knockout neonatal mice do not undergo phase 1, but exhibit a normal phase 2. We propose that, in neonatal smooth muscle phase 1 is generated by recruitment of smooth-muscle myosin heavy chain, whereas phase 2 can be generated by activation of non-muscle myosin heavy chain. We conclude that phase 1 becomes indispensable for survival and normal growth soon after birth, particularly for functions such as homeostasis and circulation.

Developmental changes in the complexity of the electrocortical activity in foetal sheep.

The foetal sheep brain develops organised sleep states from 115-120 d gestational age (dGA, term 150 dGA) alternating between REM and NREM sleep. We aimed to investigate whether maturation of REM or NREM sleep generating structures leads to the development of distinct sleep states. The electrocorticogram (ECoG) was recorded from five unanaesthetised chronically instrumented foetal sheep in utero and was analysed every 5th day between 115-130 dGA by two different non-linear methods. We calculated a non-linear prediction error which quantifies the causality of the ECoG and applied bispectral analysis which quantifies non-linear interrelations of single frequency components within the ECoG signal. The prediction error during REM sleep was significantly higher than during NREM sleep at each investigated age (P<0.0001) coincidental with poor organisation of the rhythmic pattern in the ECoG during REM sleep. At 115 dGA, organised sleep states defined behaviourally were not developed yet. The prediction error, however, showed already different states of electrocortical activity that were not detectable using power spectral analysis. The prediction error of the premature NREM sleep ECoG decreased significantly during emergence of organised sleep states between 115 and 120 dGA and continued to decrease after the emergence of distinct sleep states (P<0.05). The prediction error of the premature REM sleep ECoG did not change until 120 dGA and began to increase at 125 dGA (P<0.05). Using bispectral analysis, we showed couplings between delta waves (1.5-4 Hz) and frequencies in the range of spindle waves (4-8 and 8-12 Hz) during NREM sleep that became closer during development. The results show that maturation of ECoG synchronisation mediating structures is important for the development of organised sleep states. The further divergence of the prediction error of NREM and REM sleep after development of organised sleep states reveals continuous functional development. Thus, complementary application of non-linear ECoG analysis to power spectral analysis provide new insights in the collective behaviour of the neuronal network during the emergence of sleep states.

Signaling from beta-adrenoceptor to L-type calcium channel: identification of a novel cardiac protein kinase A target possessing similarities to AHNAK.

A novel calcium channel-associated protein of approximately 700 kDa has been identified in mammalian cardiomyocytes that undergoes substantial cAMP-dependent protein kinase (PKA) phosphorylation. It was therefore designated as phosphoprotein 700 (pp700). The pp700 interacts specifically with the beta(2) subunit of cardiac L-type calcium channels as revealed by coprecipitation experiments using affinity-purified antibodies against different calcium channel subunits. It is surprising that amino acid sequence analysis of pig pp700 revealed homology to AHNAK-encoded protein, which was originally identified in human cell lines of neural crest origin as 700-kDa phosphoprotein. Cardiac AHNAK expression was assessed on mRNA level by reverse transcriptase-polymerase chain reaction. Sequence-directed antibodies raised against human AHNAK recognized pp700 in immunoblotting and immunoprecipitation experiments, confirming the homology between both proteins. Anti-AHNAK antibodies labeled preferentially the plasma membrane of cardiomyocytes in cryosections of rat cardiac tissue and isolated cardiomyocytes. Sarcolemmal pp700/AHNAK localization was not influenced by stimulation of either the PKA or the protein kinase C pathway. In back-phosphorylation studies with cardiac biopsies, we identified distinct pp700 pools. The membrane-associated fraction of pp700 underwent substantial in vivo phosphorylation on beta-adrenergic receptor stimulation by isoproterenol, whereas the cytoplasmic fraction of pp700 was not accessible to endogenous PKA. It is important that in vivo phosphorylation occurred in that pp700 fraction which coprecipitated with the calcium channel beta subunit. We hypothesize that both phosphorylation of pp700 and its coupling to the beta subunit play a physiological role in cardiac beta-adrenergic signal transduction. Haase, H., Podzuweit, T., Lutsch, G., Hohaus, A., Kostka, S., Lindschau, C., Kott, M., Kraft, R., Morano, I. Signaling from beta-adrenoceptor to L-type calcium channel: identification of a novel cardiac protein kinase A target that has similarities to AHNAK.

Influence of different culture conditions on sarcoplasmic reticular calcium transport in isolated neonatal rat cardiomyocytes.

This study investigates sarcoplasmic reticulum (SR) calcium-(Ca2+) transport ATPase (SERCA2a) and phospholamban (PLB) in cultured spontaneously contracting neonatal rat cardiomyocytes (CM) to ascertain the function of both SR proteins under various culture conditions. The two major SR proteins were readily detectable in cultured CM by immunofluorescent microscopy using specific anti-SERCA2 and anti-PLB antibodies. Double labeling technique revealed that PLB-positive CM also labeled with anti-SERCA2. Coexpression of SERCA2 and PLB in CM was supported by measurement of cell homogenate oxalate-supported Ca2+ uptake which was completely inhibited by thapsigargin and stimulated by protein kinase A-catalyzed phosphorylation. Under serum-free conditions, incubation of CM with the SERCA2a expression modulator 3,3', 5-triiodo-L-thyronine (100 nM, 72 h) resulted in elevated Ca2+ uptake of +33%. Specific Ca2+ uptake activity was not altered if insulin was omitted from the serum-free culture medium but total SR Ca2+ transport activity was reduced under this culture condition. The results indicate that primary culture of spontaneously contracting neonatal rat CM can be employed as a useful model system for investigating both short- and long-term mechanisms determining the Ca2+ re-uptake function of the SR under defined culture conditions.

A new efficient method for transfection of neonatal cardiomyocytes using histone H1 in combination with DOSPER liposomal transfection reagent.

Although cationic lipids are successfully used for gene transfer in vitro, primary cells such as neonatal cardiomyocytes frequently resist efficient transfection. We show here that the polycationic lipid DOSPER in combination with histone H1 was much more efficient in transfection of neonatal cardiomyocytes than DOSPER alone or other cationic lipids. This has been shown for transfection with the reporter plasmids pSV beta-gal and pCMV luc. If viral transfections are not possible, this mild method is an alternative to transfect cardiomyocytes.

[Revision operations after tenotomy of the medial rectus muscle]. / Revisionsoperationen nach Tenotomie des Musculus rectus medialis.

BACKGROUND: Although tenotomy of the medial rectus (MR) is generally regarded to be obsolete, consecutive exotropia after this procedure, requiring a reoperation, still occurs. PATIENTS AND METHODS: In 143 patients a reoperation after tenotomy of the MR had to be performed because of consecutive exotropia. Either only the MR was sutured at the original insertion (advancement; this constitutes group 1, n = 101) or the lateral rectus (LR) was recessed in addition (group 2, n = 12). The recession of the LR was only added if the adduction was not distinctly limited and if the distance of the MR from the limbus was less than 16 mm. We wanted to find out whether the procedure in group 1 or 2 gave the better results. RESULTS: In group 1 the muscle sheath of the MR was found at a distance of 7 mm (median), the muscle itself at a distance of 18 mm from the limbus (confidence interval 13.5-25 mm). In group 2 the distance of the muscle sheath from the limbus was similar to group 1, the muscle itself was found already at a distance of 12 mm from the limbus (confidence interval 6-18 mm). After reinsertion of the muscle at the original insertion without recession of the LR, a distinct limitation of abduction combined with a globe retraction was seen immediately after surgery. A spontaneous release of the old contracture reduced these troublesome side effects. Three months postoperatively the initial surgical effect had diminished to 83%. The average postoperative squint angle was -3 degrees at 5 m and -4 degrees at 0.33 m with a high scatter. In group 1 [group 2 in brackets], the range of the horizontal motility was improved by 15 degrees [10 degrees] (median) and the incomitance, i.e. the difference between the angle of squint at 25 degrees gaze to the right and to the left, by 4 degrees [0 degrees, i.e. no improvement]. Thus, this postoperative improvement was smaller in cases of simultaneous recession of the LR (group 2). DISCUSSION: The most important aim in a reoperation after tenotomy of the MR is to find the muscle itself and to suture it to the original insertion. It can be expected that the contracture of the MR will loosen when the muscle is put under increased tension. This effect will be less if the LR is recessed in addition to the advancement of the MR. Consistent with this assumption, our not randomized, retrospective study revealed a better horizontal motility after advancement of the MR alone. Because of the difficulties in revising a tenotomy, we strongly advise a graded recession rather than any form of tenotomy.

Differential influences of carnitine palmitoyltransferase-1 inhibition and hyperthyroidism on cardiac growth and sarcoplasmic reticulum phosphorylation.

To characterize interventions resulting in 'physiological' growth of the heart, Wistar-Kyoto (WKY) rats and spontaneously hypertensive rats (SHR) had hyperthyroidism induced (0.05 mg.kg-1.day-1 triiodothyronine for 6 days) or were treated with a high dose of the carnitine palmitoyltransferase-1 inhibitor, etomoxir (15 mg.kg-1.day-1 for 5 weeks). Etomoxir increased cardiac growth evenly, but hyperthyroidism resulted in an over-proportional higher right ventricular weight. Both interventions increased the proportion of the myosin isozyme V1. The rate of sarcoplasmic reticulum (SR) Ca2+ uptake was increased to a greater extent in hyperthyroid rats than in etomoxir-treated rats (P < 0.05). Left ventricular levels of immunoreactive phospholamban (semiquantitative ELISA) were moderately decreased (P < 0.05) in hyperthyroid rats but not in etomoxir-treated rats. The protein kinase A-catalyzed in vitro 32P-incorporation into the SR Ca2+ pump modulator phospholamban was greatly reduced (P < 0.05) in hyperthyroid rats, indicating an increased in vivo phosphorylation. Etomoxir did not affect phospholamban phosphorylation in WKY rats. Thus, both a higher in vivo phospholamban phosphorylation state and a greater number of active Ca2+ pumps contributed to an increased rate of SR Ca2+ uptake in hyperthyroidism. The etomoxir treatment primarily increased the number of active Ca2+ pumps. A scheme is proposed focusing on long-term vs short-term regulation of the SR Ca2+ pump/phospholamban system in diseased states.

[Surgical treatment of mediastinal tumors from personal material]. / Chirurgiczne leczenie guzów sródpiersia w materiale wlasnym.

90 patients with mediastinal tumors treated surgically was analysed. It was find, that tumor mostly was localized in anterior superior mediastinum, had benign character and in over half of cases was derived from thymus. 75% of mediastinal tumors were primary. In over 50% patients longitudinal sternotomy was performed. Radical excision of the tumor was possible nearly in 90% cases.

Structure of the gene for human butyrylcholinesterase. Evidence for a single copy.

We have isolated five genomic clones for human butyrylcholinesterase (BChE), using cDNA probes encoding the catalytic subunit of the hydrophilic tetramer [McTiernan et al. (1987) Proc. Natl. Acad. Sci. U.S.A. 84, 6682-6686]. The BChE gene is at least 73 kb long and contains four exons. Exon 1 contains untranslated sequences and two potential translation initiation sites at codons -69 and -47. Exon 2 (1525 bp) contains 83% of the coding sequence for the mature protein, including the N-terminal and the active-site serine, and a third possible translation initiation site (likely functional), at codon -28. Exon 3 is 167 nucleotides long. Exon 4 (604 bp) codes for the C-terminus of the protein and the 3' untranslated region where two polyadenylation signals were identified. Intron 1 is 6.5 kb long, and the minimal sizes of introns 2 and 3 are estimated to be 32 kb each. Southern blot analysis of total human genomic DNA is in complete agreement with the gene structure established by restriction endonuclease mapping of the genomic clones: this strongly suggests that the BChE gene is present in a single copy.

Histopathologic findings in ectopic tubal pregnancy.

In 141 consecutive cases of tubal ectopic pregnancy at Hermann Hospital in Houston, Texas, the histologic appearance of 129 surgically removed fallopian tubes containing ectopic pregnancies was reviewed and compared with an age- and race-matched control population. There was a higher incidence of chronic salpingitis (88 versus 2%) and salpingitis isthmica nodosa (SIN) (43 versus 5%). The ectopic pregnancy patients had a higher incidence of pelvic inflammatory disease, gonorrhea, previous abortions, bitubal ligation, intrauterine device use, and previous abdominal surgery. In our population, chronic salpingitis was the most commonly associated finding. The increase in SIN was associated with postinflammatory changes (89%). We also found that ectopic tubal pregnancies may grow either intratubally or extratubally by villous invasion into the wall and blood vessels; therefore, surgical salvage of the fallopian tube by extracting the products of conception will not always be curative.

Brain cDNA clone for human cholinesterase.

A cDNA library from human basal ganglia was screened with oligonucleotide probes corresponding to portions of the amino acid sequence of human serum cholinesterase (EC 3.1.1.8). Five overlapping clones, representing 2.4 kilobases, were isolated. The sequenced cDNA contained 207 base pairs of coding sequence 5' to the amino terminus of the mature protein in which there were four ATG translation start sites in the same reading frame as the protein. Only the ATG coding for Met-(-28) lay within a favorable consensus sequence for functional initiators. There were 1722 base pairs of coding sequence corresponding to the protein found circulating in human serum. The amino acid sequence deduced from the cDNA exactly matched the 574 amino acid sequence of human serum cholinesterase, as previously determined by Edman degradation. Therefore, our clones represented cholinesterase (EC 3.1.1.8) rather than acetylcholinesterase (EC 3.1.1.7). It was concluded that the amino acid sequences of cholinesterase from two different tissues, human brain and human serum, were identical. Hybridization of genomic DNA blots suggested that a single gene, or very few genes, coded for cholinesterase.